Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
UnitedHealthcare Community Plans may have monthly quantity limitations on certain medications. Prescriptions for quantities greater than the indicated monthly limits will require prior authorization. Quantity limits exist to promote efficient medication dosing and safe dosing administration.
Quantity limits also apply to certain classes of medications. Patients have access to any FOUR medications from the following classes in a 30-day period: benzodiazepines, sedative hypnotic agents, barbiturates, and select muscle relaxants. Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits.
Additions to the Quantity Limit (QL) program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization (PA) process.
In response to the U.S. opioid epidemic, UnitedHealthcare has developed programs to help our members receive the care and treatment they need safely and effectively.
We’ve also established measures based on the Centers for Disease Control and Prevention’s (CDC) opioid treatment guidelines to help prevent overuse of short-acting and long-acting opioid medications.
CoverMyMeds streamlines the medication prior authorization process, electronically connecting providers, pharmacists and plan/PBMs to improve time to therapy and decrease prescription abandonment with electronic prior authorization.
The PreCheck MyScript Solution on the UnitedHealthcare Provider Portal helps make it easy to run a pharmacy trial claim and get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members.
Specialty medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure for the member’s coverage.
Pharmacy benefit medications are typically self-administered by the patient or a caregiver, after filling the prescription through a pharmacy. These medications are labeled for self-administration by the Food and Drug Administration but may require some instruction to the patient or caregiver.
Typically, medications administered orally, topically or through subcutaneous injection by the patient or a caregiver after receiving instruction are covered under the pharmacy benefit.
Medical benefit medications are typically administered by a health care professional and monitored by a health care professional. The medication is administered in a physician office, at home, in an ambulatory infusion suite or in an outpatient facility. These medications can be administered by infusion, injection or intramuscularly with the help of an infusion nurse.
Specialty Pharmacy medications can be shipped from a specialty pharmacy directly to a health care setting (i.e., sourced) or a provider may purchase them directly using their standard distribution process (i.e., buy and bill). If the drugs are administered at home, they may be shipped from a specialty pharmacy directly to the member’s home.
Coverage of a requested medication depends on the member’s Medicaid coverage as determined by the State Medicaid agency, and the availability of a specific drug from a network specialty pharmacy may vary.
Medications obtained through a specialty pharmacy will be directly billed to the member’s health plan.
To locate a contracted specialty pharmacy, download the list: Provider Vendor Assistance List - Specialty Pharmacy.
Specialty Program Description
UnitedHealthcare Community Plan administers a Specialty Pharmacy Management Program that provides high quality, cost effective care for our members. This program optimizes the patient experience and clinical outcomes by utilizing a network of specialty pharmacies that offer clinical programs which include, but are not limited to, educating and supporting our members concerning their chronic condition(s), promoting medication adherence and reducing the risk of side effects, and promoting multi-disciplinary practice and collaboration to achieve continuity of care.
Our network specialty pharmacies are selected based on their clinical expertise, the quality of clinical management and adherence programs provided, and overall cost of therapy. Specialty pharmacy providers are specifically trained on specialty medications, the conditions they treat, and can provide comprehensive clinical services. The contracting / credentialing process ensures consistency with the requirements, the highest level of quality provided to members, and access to all specialty pharmacy medications.
The specialty pharmacies provide patient education and training, not only for the medication, but also the chronic condition being treated. The specialty teams proactively reach out to patients each month prior to refilling their prescription. During this outreach, patients are asked if they have questions about their condition or drugs, and if they would like to speak directly to a clinician. Medication adherence is also checked, with any potential issues identified and addressed. Additionally, their Member Support Services provides patients with access to a clinician trained in their condition and drug therapy 24 hours a day, 7 days week.
Some of the services our network specialty pharmacies offer include:
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Community Plan - QUEST Integration Program.
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete RP (Regional PPO SNP) R3175-003.